FORM A ELIGIBILITY QUESTIONNAIRE FOR TESTING ACCOMMODATIONS (Please print or type) To be completed by all applicants requesting testing accommodations. This form is part of the application for admission to the Iowa Bar Examination. 1. Background Information: FULL NAME __________________________________________________________________ Last First Middle MAILING ADDRESS ___________________________________________ ________________ Street Address or P.O. Box Number ___________________________________________________________ City, State and Zip Code DRIVERS LICENSE NUMBER ______________ _____________________________________ TELEPHONE NUMBER ___________________________ _____________________________ Residence Work Providing your social security number is voluntary, pursuant to the Federal Privacy Act of 1974. However, providing your social security number assists in expediting the charac ter review process. Your social security number will be used for purposes of investigation and verification, so as to avoid errors of identity that might introduce problems and delays into the certification and licensure process. SOCIAL SECURITY NUMBER _________________________________________________ 2. Nature of Your Disability (check all that apply): _____ Blind _____ Other Physical Disability _____ Other Visual Impairment _____ Psychological Disability _____ Deaf _____ Specific Learning Disability _____ Other Hearing Impairment _____ Other (please explain) 3. Nature and Extent of Disability: Please attach a detailed narrative describing the nature and extent of your disability. *What disability do you have? *Describe functional limitations related to your disability that directly affect your ability to take the examination. *When did you first acquire the disability (approximate date and age)? *When was the disability first diagnosed by Physician/Licensed professional (date & age) *By whom (name, address and degree)? *What treatment is currently prescribed? *By whom? -1- 4. Past Accommodations Granted for your Disability: >>>> 2 A. Were you granted testing accommodations for taking the SAT, ACT, GRE, GMAT or any other professional examination? _______ B. Did you use disabled-student or tutoring services while enrolled in college? _______ C. Did you receive accommodations for classroom tests while in college? _______ If YES to A, B or C, describe all accommodations you were granted: If NO, explain why accommodations were not requested or were not granted: D. Were you granted accommodations for taking the LSAT or MPRE Examinations? _____ If YES, describe all accommodations you were granted. If NO, explain why accommodations were not requested or were not granted: -2- E. Were you granted testing accommodations in law school? _______ If YES, on what >>>> 3 information did the school base accommodations? Include the source of information, (such as the person, institution) and tests. Specify the accommodations and years you were granted these accommodations. If YES, forward a copy of FORM F to the law school that provided accommodations. F. Were you granted testing accommodations for any other states bar exam? Yes/No 5. Accommodations Requested: Describe all accommodations you believe are necessary for you to take the examination 6. Applicants Signature: I am aware that it is my responsibility to file a complete application and understand that it will be returned to me if found to be incomplete. I have attached all original supporting affidavits or documents. I further understand it is my responsibility to supplement the application as requested. I hereby declare under penalty of perjury under the laws of the State of Iowa that the foregoing statements are true and correct. I understand that false statements made herein could result in denial of my admission to practice law based on moral character grounds. ________________________________ _____________________________ Signature of Applicant Date The Board of Law Examiners reserves the right to make a final judgment concerning testing accommodations and may, in its discretion, seek an independent evaluation from a medical specialist, psychologist, psychiatrist or other qualified specialist. Each case will be evaluated on its facts. 2000 -3-